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Koyama K, Anno T, Kimura Y, Kawasaki F, Kaku K, Tomoda K, Kaneto H. Pathology of Ketoacidosis in Emergency of Diabetic Ketoacidosis and Alcoholic Ketoacidosis: A Retrospective Study. J Diabetes Res 2024; 2024:8889415. [PMID: 38225984 PMCID: PMC10789514 DOI: 10.1155/2024/8889415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 12/10/2023] [Accepted: 12/20/2023] [Indexed: 01/17/2024] Open
Abstract
This study is aimed at examining which factors are useful for the diagnosis and distinction of ketoacidosis. We recruited 21 diabetic ketoacidosis (DKA) and alcoholic ketoacidosis (AKA) patients hospitalized in Kawasaki Medical School General Medical Center from April 2015 to March 2021. Almost all patients in this study were brought to the emergency room in a coma and hospitalized. All patients underwent blood gas aspiration and laboratory tests. We evaluated the difference in diagnosis markers in emergencies between DKA and alcoholic ketoacidosis AKA. Compared to AKA patients, DKA patients had statistically higher values of serum acetoacetic acid and lower values of serum lactate, arterial blood pH, and base excess. In contrast, total ketone bodies, β-hydroxybutyric acid, and β-hydroxybutyric acid/acetoacetic acid ratio in serum did not differ between the two patient groups. It was shown that evaluation of each pathology such as low body weight, diabetes, liver dysfunction, and dehydration was important. It is important to perform differential diagnosis for taking medical histories such as insulin deficiency, alcohol abuse, or starvation as the etiology in Japanese subjects with DKA or AKA. Moreover, it is important to precisely comprehend the pathology of dehydration and alcoholic metabolism which would lead to appropriate treatment for DKA and AKA.
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Affiliation(s)
- Katsumasa Koyama
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Yukiko Kimura
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, Okayama 700-8505, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki 701-0192, Japan
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2
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Nishizawa T, Matsumoto T, Todaka T, Sasano M. Alcoholic ketoacidosis evaluated with a point-of-care capillary beta-hydroxybutyrate measurement device. Alcohol 2023; 112:41-49. [PMID: 37453462 DOI: 10.1016/j.alcohol.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 06/01/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The diagnosis of alcoholic ketoacidosis (AKA) has traditionally been made based only on clinical history and the presence of severe metabolic acidosis with a high anion gap (AG); however, the concentration of beta-hydroxybutyrate (BOHB), a pivotal ketone body in AKA, is not evaluated in most cases. The aim of this study was to clarify the clinical spectrum of AKA in terms of the severity of ketoacidosis by using a point-of-care capillary BOHB measurement device. METHODS This retrospective case series was conducted at a Japanese private teaching hospital. Patients with suspected AKA, based on their clinical history, who underwent BOHB measurement using a point-of-care capillary measurement device in the emergency department, were included. Data on their clinical presentations, blood tests, and treatments were collected, described, and compared between patients with a BOHB concentration higher than 3.0 mmol/L (H-BOHB) and those with a concentration less than 3.0 mmol/L (L-BOHB). RESULTS A total of 83 patients were included in this study. Sixty-eight patients were categorized as having H-BOHB and 15 as having L-BOHB. Nausea (71%), vomiting (71%), tachycardia (76%), and tachypnea (46%) were commonly observed at presentation. Hyponatremia (46%), hypokalemia (34%), hypomagnesemia (42%), and hyperphosphatemia (41%) were frequent electrolyte abnormalities upon presentation. Rehydration with balanced crystalloids and glucose-containing intravenous fluids, electrolyte supplementation, and thiamine replacement were the major treatments. The mean length of stay in the ICU and hospital were 4.4 and 7.0 days, respectively, with low overall mortality (1%). The H-BOHB and L-BOHB groups did not differ in terms of clinical data. Seventy percent of patients with L-BOHB had severe metabolic acidosis with a high AG due to hyperlactatemia (mean lactate concentration: 8.5 mmol/L). CONCLUSIONS We described the clinical features of AKA measured by using a point-of-care capillary BOHB measurement device. Although certain patients diagnosed with AKA based only on their clinical history had predominant lactic acidosis with minor elevations in BOHB concentration, the BOHB concentration had no effect on the clinical spectrum of AKA in this study.
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Affiliation(s)
- Takuya Nishizawa
- Department of Intensive Care Medicine, Nakagami Hospital, 610 Noborikawa, Okinawa City, Okinawa, 904-2195, Japan.
| | - Takashi Matsumoto
- Department of Intensive Care Medicine, Nakagami Hospital, 610 Noborikawa, Okinawa City, Okinawa, 904-2195, Japan
| | - Takafumi Todaka
- Department of Intensive Care Medicine, Nakagami Hospital, 610 Noborikawa, Okinawa City, Okinawa, 904-2195, Japan
| | - Mikio Sasano
- Department of Intensive Care Medicine, Nakagami Hospital, 610 Noborikawa, Okinawa City, Okinawa, 904-2195, Japan
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Knight-Dunn L, Gorchynski J. Alcohol-Related Metabolic Emergencies. Emerg Med Clin North Am 2023; 41:809-819. [PMID: 37758425 DOI: 10.1016/j.emc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.
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Affiliation(s)
| | - Julie Gorchynski
- Department of Emergency Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
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Iesaka H, Nomoto H, Atsumi T. Alcoholic Ketoacidosis Manifesting With Hypoglycemia Exacerbated by an SGLT2 Inhibitor in a Nondiabetic Patient. Mayo Clin Proc 2023; 98:947-948. [PMID: 37270274 DOI: 10.1016/j.mayocp.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/07/2023] [Accepted: 04/06/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Hiroshi Iesaka
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Nomoto
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Mung SM, Fonseca I, Azmi S, Balmuri LMR. Prolonged diabetic ketoacidosis due to
SGLT2
inhibitor use and low‐carbohydrate diet. PRACTICAL DIABETES 2023. [DOI: 10.1002/pdi.2446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Takayama K, Obata Y, Maruo Y, Yamaguchi H, Kosugi M, Irie Y, Hazama Y, Yasuda T. Metformin-associated Lactic Acidosis with Hypoglycemia during the COVID-19 Pandemic. Intern Med 2022; 61:2333-2337. [PMID: 35598993 PMCID: PMC9424080 DOI: 10.2169/internalmedicine.9179-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Metformin-associated lactic acidosis (MALA) is an extremely rare but life-threatening adverse effect of metformin treatment. The lifestyle changes associated with the coronavirus disease 2019 (COVID-19) pandemic may increase the potential risk of MALA development in patients with diabetes. We herein report a 64-year-old Japanese man taking a small dose of metformin who presented with MALA accompanied by hypoglycemia secondary to increased alcohol consumption triggered by lifestyle changes during the pandemic. Physicians should prescribe metformin judiciously to prevent MALA development and pay close attention to lifestyle changes in patients at risk for MALA during the COVID-19 pandemic.
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Affiliation(s)
- Kana Takayama
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Yoshinari Obata
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Yumiko Maruo
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Hiroki Yamaguchi
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Motohiro Kosugi
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Yoko Irie
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Yoji Hazama
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
| | - Tetsuyuki Yasuda
- Department of Diabetes, Metabolism and Endocrinology, Osaka Police Hospital, Japan
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Soe MZ, Ching KM, Teah KM, Lim CH, Jamil J, Yeap BT. Ketoacidosis can Be alcohol in origin: A case report. Ann Med Surg (Lond) 2022; 79:104023. [PMID: 35860098 PMCID: PMC9289420 DOI: 10.1016/j.amsu.2022.104023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Alcoholic ketoacidosis (AKA) is a common reversible biochemical pathology arising from hyperketonaemia in patients with a history of chronic alcohol consumption. It is typically fatal when there is a delay in early recognition and management. A further complicating factor is that this condition is frequently confused with diabetic ketoacidosis (DKA). Case presentation This report presents the case study of an elderly Chinese man with a 40-year history of alcohol consumption. The patient presented with acute shortness of breath, generalised abdominal pain, and vomiting. Blood gas analysis indicated severe high anion gap metabolic acidosis (HAGMA) with elevated serum ketones and modest hyperglycaemia which was initially treated as diabetic ketoacidosis (DKA). A diagnosis of AKA was later made after obtaining a thorough history of his binge drinking. The patient subsequently responded well to thiamine and aggressive fluid resuscitation. This case highlights the importance of a well-documented patient history and in-depth knowledge of ketoacidosis. Discussion AKA must be suspected in patients with a history of chronic alcohol consumption and dependence. The symptoms are non-specific such as abdominal pain, nausea, vomiting and diarrhoea. The latter two result in malnutrition and starvation subsequently leading to hyperketonaemia, hypovolaemia and HAGMA. AKA should be clearly differentiated from DKA to prevent mismanagement. The mainstay of management of AKA is thiamine, fluid resuscitation and good sugar control to prevent Wernicke's encephalopathy. Conclusion A precise patient's medical history is crucial to prevent misdiagnosis. A non-diabetic patient with a history of chronic alcohol consumption who presents with severe HAGMA, hyperketonaemia and dysglycaemia should raise a clinical suspicion of AKA. Thiamine and judicious fluid resuscitation as well as electrolytes and malnutrition correction should be promptly initiated in patients with AKA. Good family, social support and rehabilitation programs are crucial to help patients with alcohol abuse. AKA can occur in non-diabetic patients with chronic alcoholism who presents with severe HAGMA and hyperketonaemia. Thiamine, fluid resuscitation as well electrolytes and malnutrition correction should be promptly managed in patients with AKA. Good family, social support and rehabilitation programs are crucial to help patients with alcohol abuse.
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Aung NL, Vakani V, Wassel M. A Case of Hyperglycemic Ketoacidosis in a Patient Without Diabetes. Cureus 2022; 14:e24560. [PMID: 35664400 PMCID: PMC9148192 DOI: 10.7759/cureus.24560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/09/2022] Open
Abstract
We present the case of a 70-year-old Caucasian female who presented to the emergency department with acute pancreatitis and ketoacidosis. An extensive workup for ketoacidosis showed that the patient had hyperglycemic ketoacidosis with findings similar to diabetic ketoacidosis (DKA). However, the patient did not have a history of diabetes, and no diagnosis of diabetes could be made on the current admission as well. Ketoacidosis was determined to be induced by acute hyperglycemia secondary to pancreatitis, which suppresses insulin secretion transiently. It is important to note that DKA can be seen in patients with different types of diabetes and is not just limited to type 1 diabetes.
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Umadat G, Moktan V, Shapiro B. 61-Year-Old Man With Nausea and Vomiting. Mayo Clin Proc 2022; 97:170-175. [PMID: 34862073 DOI: 10.1016/j.mayocp.2021.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Goyal Umadat
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Varun Moktan
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Brian Shapiro
- Advisor to residents and Consultant in Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL.
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Hoyte C, Schimmel J, Hadianfar A, Banerji S, Nakhaee S, Mehrpour O. Toxic alcohol poisoning characteristics and treatments from 2000 to 2017 at a United States regional poison center. Daru 2021; 29:367-376. [PMID: 34709587 DOI: 10.1007/s40199-021-00418-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/30/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Toxic alcohol exposures are an ongoing concern in the United States. In the US, few studies characterize the local epidemiology of toxic alcohols over time. OBJECTIVES The objective was to examine the incidence of toxic alcohol ingestions and changes in management over time. METHODS This retrospective cohort study evaluates toxic alcohol ingestion phone calls to a regional poison center in the United States covering four states. Data were queried for this poison center from the National Poison Data System (NPDS) using generic codes for each toxic alcohol. Inclusion criteria were ingestion of toxic alcohol, age ≥ 13 years, from January 1, 2000 to Dec 31, 2017. Exclusion criteria were unrelated effects coded in the medical outcome, duplicate data, or incomplete demographic data. RESULTS Of 926 subjects (adults and teenagers), 71.5% were male, and the mean age was 34.5 years. Toxic alcohol ingestion was more common in individuals younger than 40 years, with a significant relationship between age and intentional abuse or misuse (p = 0.001). There was also a significant relationship between age and reason for ingestion, with younger patients more likely to be suicidal (p < 0.001). Ethyleneglycol was the most common toxic alcohol. There was no change in the incidence of toxic alcohol ingestions over the study period. The mortality rate was 1.7%, and 31.2%of patients were hospitalized in a critical care unit. Major effects and death were more common in younger patients (p < 0.001). There was a significant difference in medical outcomes based on the type of toxic alcohol(p = 0.03). Fomepizole was the most common treatment. A Poisson regression model found no change in fomepizole use during the study period (p = 0.1). Ethanol administration over the study period increased (p = 0.02), while hemodialysis decreased (p = 0.02). CONCLUSION Data obtained from a single regional United States poison center showed low mortality related to toxic alcohol ingestions. The most prevalent toxic alcohol was Ethylene glycol. In all cases, toxic alcohol ingestion was higher in the 20-29-year-old age group. Reasons for ingestion, in most cases, were suicidal. Fomepizole was the most common treatment, ethanol administration as an antidote is rising, and hemodialysis utilization is decreasing. Data may not be nationally representative.
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Affiliation(s)
| | - Jonathan Schimmel
- Department of Emergency Medicine, Division of Medical Toxicology, Mount Sinai Hospital Icahn School of Medicine, New York, NY, USA
| | - Ali Hadianfar
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shireen Banerji
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO, USA
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Omid Mehrpour
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA. .,Scientific Unlimited horizon, Tucson, AZ, USA.
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Long B, Lentz S, Gottlieb M. Alcoholic Ketoacidosis: Etiologies, Evaluation, and Management. J Emerg Med 2021; 61:658-665. [PMID: 34711442 DOI: 10.1016/j.jemermed.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alcoholic ketoacidosis (AKA) is defined by metabolic acidosis and ketosis in a patient with alcohol use. This is a common presentation in the emergency department (ED) and requires targeted therapies. OBJECTIVE This narrative review evaluates the pathogenesis, diagnosis, and management of AKA for emergency clinicians. DISCUSSION AKA is frequently evaluated and managed in the ED. The underlying pathophysiology is related to poor glycogen stores and elevated nicotinamide adenine dinucleotide and hydrogen. This results in metabolic acidosis with elevated beta-hydroxybutyrate levels. Patients with AKA most commonly present with a history of alcohol use (acute or chronic), poor oral intake, gastrointestinal symptoms, and ketoacidosis on laboratory assessment. Patients are generally dehydrated, and serum glucose can be low, normal, or mildly elevated. An anion gap metabolic acidosis with ketosis and electrolyte abnormalities are usually present on laboratory evaluation. Management includes fluid resuscitation, glucose and vitamin supplementation, electrolyte repletion, and evaluation for other conditions. CONCLUSIONS Emergency clinician knowledge of the evaluation and management of AKA is essential in caring for these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Liu J, Li X, Wu J, Chen Y, Li H, Tian Z. Non-diabetic ketoacidosis: A case of alcoholic ketoacidosis accompanied by hyperglycemia. Am J Emerg Med 2021; 52:270.e5-270.e8. [PMID: 34474943 DOI: 10.1016/j.ajem.2021.08.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/24/2021] [Accepted: 08/23/2021] [Indexed: 11/19/2022] Open
Abstract
Alcoholic ketoacidosis (AKA) lacks specific clinical presentation. The results of blood testing commonly show hemoconcentration, elevated β-hydroxybutyrate levels, and acidosis in patients with AKA. Herein, we report a case of AKA accompanied by hyperglycemia and review the related literature. Case report: AKA associated with hyperglycemia is rare, and its pathogenesis is similar to that of diabetic ketoacidosis, thereby making differentiation challenging. Accordingly, AKA is easily misdiagnosed by endocrinologists. The main symptoms of a 37-year-old female included hyperglycemia, elevated β-hydroxybutyrate levels, and metabolic acidosis. Primary clinical presentations were severe nausea and vomiting. The patient initially diagnosed with DKA were eventually confirmed as AKA, who recovered after active therapy with rehydration and correction of hyperglycemia, electrolyte imbalance, and ketosis. This study provides a reference for clinicians to reduce missed diagnosis and the misdiagnosis rates of AKA.
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Affiliation(s)
- Jiaojiao Liu
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China; Department of Graduate School, Yan'an University, Yan'an, Shaanxi 716000, China
| | - Xiangshan Li
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China; Department of Graduate School, Yan'an University, Yan'an, Shaanxi 716000, China
| | - Jiali Wu
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China; Department of Graduate School, Yan'an University, Yan'an, Shaanxi 716000, China
| | - Yazhuo Chen
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China; Department of Graduate School, Yan'an University, Yan'an, Shaanxi 716000, China
| | - Heng Li
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China
| | - Zhufang Tian
- Department of Endocrinology, Xi'an Central Hospital, Xi'an, Shaanxi 710003, China.
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Sato H, Kyan R, Kamada C, Kaku M, Sato S, Tawara T, Sakawaki E, Sakawaki S, Takeyama Y. Transient total blindness associated with alcoholic ketoacidosis. Acute Med Surg 2021; 8:e660. [PMID: 34012551 PMCID: PMC8112226 DOI: 10.1002/ams2.660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background Methanol poisoning is often suspected in patients with high anion gap metabolic acidosis and visual deficits. Although alcoholic ketoacidosis can cause high anion gap metabolic acidosis, reports on vision loss are limited. We report the case of a patient with alcoholic ketoacidosis with transient total blindness. Case Presentation A 56‐year‐old man complaining of total blindness was transferred to our hospital. Physical examination revealed a clear consciousness and mydriasis with an absence of pupillary light reflex. Blood analysis revealed high anion gap metabolic acidosis with a high ketone body concentration. Alcoholic ketoacidosis was diagnosed because the patient had a chronic alcohol abuse history and denied methanol intake. As acidemia improved because of fluid infusion and glucose and vitamin B1 supplementation, his visual acuity recovered. He was discharged after 44 days without visual deficits. Conclusion Patients with alcoholic ketoacidosis may present with acute vision loss, which recovers along with treatment.
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Affiliation(s)
- Hiroki Sato
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Ryoko Kyan
- Clinical Toxicology Center Saitama Medical University Hospital Saitama Japan
| | - Chinami Kamada
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Mitsunori Kaku
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Shota Sato
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Toshihiro Tawara
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Eiji Sakawaki
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Sonoko Sakawaki
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
| | - Yoshihiro Takeyama
- Department of Emergency Medicine Hakodate Municipal Hospital Hakodate Japan
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Relationship between betahydroxybutyrate (BHB) and acetone concentrations in postmortem blood and cause of death. Forensic Sci Int 2021; 321:110726. [PMID: 33631622 DOI: 10.1016/j.forsciint.2021.110726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/06/2021] [Accepted: 02/14/2021] [Indexed: 11/23/2022]
Abstract
Unexpected death caused by diabetic or alcoholic ketoacidosis is easily overlooked due to the non-specific symptoms. Although the acid betahydroxybutyrate (BHB) is the most abundant ketone body formed in conditions with ketoacidosis, routine analysis in postmortem investigations often only includes the neutral ketone body acetone. This study aims to evaluate the usefulness of implementing routine BHB analysis in postmortem cases, by investigating the relationship between BHB and acetone concentrations in postmortem blood and the main cause of death. From our database of forensic autopsy cases examined from 2012 to 2015, there were 376 cases with BHB and/or acetone detected in postmortem blood that could be paired with data from the Norwegian Cause of Death Registry. Cases were categorized into three groups based on cause of death: "Diabetes-related" (n = 38), "Alcohol-related" (n = 35) and "Other" (n = 303). Analysis of BHB in blood was performed using UHPLC-MS/MS (limit of quantification (LOQ) 52 mg/L) and of acetone using HS-GC-FID (LOQ 87 mg/L). For the purpose of the study, the acetone method was also validated for a LOQ of 23 mg/L. The median BHB concentration was significantly higher in the group of diabetes-related deaths (671 mg/L, range 68-1311 mg/L) compared to the group of alcohol-related (304 mg/L, range 65-1555 mg/L, p <0.001) and other causes of deaths (113 mg/L, range 0-1402 mg/L, p <0.001). In seven deaths (1.9%), the BHB blood concentration was above the suggested pathological threshold of 250 mg/L, without detection of acetone in blood above 23 mg/L. In 15% of deaths by other causes than diabetes or alcohol, a pathologically significant BHB blood concentration was detected. Our results indicate that BHB is a more reliable marker of pathologically significant ketoacidosis than acetone, and we suggest that BHB should be routinely analyzed in postmortem investigations.
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Cohen ET, Su MK, Biary R, Hoffman RS. Distinguishing between toxic alcohol ingestion vs alcoholic ketoacidosis: how can we tell the difference? Clin Toxicol (Phila) 2021; 59:715-720. [DOI: 10.1080/15563650.2020.1865542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Emily T. Cohen
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mark K. Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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Sheriff L, Khan RS, Saborano R, Wilkin R, Luu NT, Gunther UL, Hubscher SG, Newsome PN, Lalor PF. Alcoholic hepatitis and metabolic disturbance in female mice: a more tractable model than Nrf2-/- animals. Dis Model Mech 2020; 13:dmm046383. [PMID: 33067186 PMCID: PMC7790192 DOI: 10.1242/dmm.046383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022] Open
Abstract
Alcoholic hepatitis (AH) is the dramatic acute presentation of alcoholic liver disease, with a 15% mortality rate within 28 days in severe cases. Research into AH has been hampered by the lack of effective and reproducible murine models that can be operated under different regulatory frameworks internationally. The liquid Lieber-deCarli (LdC) diet has been used as a means of ad libitum delivery of alcohol but without any additional insult, and is associated with relatively mild liver injury. The transcription factor nuclear factor-erythroid 2-related factor 2 (Nrf2) protects against oxidative stress, and mice deficient in this molecule are suggested to be more sensitive to alcohol-induced injury. We have established a novel model of AH in mice and compared the nature of liver injury in C57/BL6 wild-type (WT) versus Nrf2-/- mice. Our data showed that both WT and Nrf2-/- mice demonstrate robust weight loss, and an increase in serum transaminase, steatosis and hepatic inflammation when exposed to diet and ethanol. This is accompanied by an increase in peripheral blood and hepatic myeloid cell populations, fibrogenic response and compensatory hepatocyte regeneration. We also noted characteristic disturbances in hepatic carbohydrate and lipid metabolism. Importantly, use of Nrf2-/- mice did not increase hepatic injury responses in our hands, and female WT mice exhibited a more-reproducible response. Thus, we have demonstrated that this simple murine model of AH can be used to induce an injury that recreates many of the key human features of AH - without the need for challenging surgical procedures to administer ethanol. This will be valuable for understanding of the pathogenesis of AH, for testing new therapeutic treatments or devising metabolic approaches to manage patients whilst in medical care.This article has an associated First Person interview with the joint first authors of the paper.
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Affiliation(s)
- Lozan Sheriff
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Reenam S Khan
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Raquel Saborano
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard Wilkin
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Nguyet-Thin Luu
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Ulrich L Gunther
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Institute of Chemistry and Metabolomics, University of Lübeck, 23562 Lübeck, Germany
| | - Stefan G Hubscher
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Liver Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK
- Department of Cellular Pathology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Philip N Newsome
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Patricia F Lalor
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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Magnesium, Calcium, Potassium, Sodium, Phosphorus, Selenium, Zinc, and Chromium Levels in Alcohol Use Disorder: A Review. J Clin Med 2020; 9:jcm9061901. [PMID: 32570709 PMCID: PMC7357092 DOI: 10.3390/jcm9061901] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023] Open
Abstract
Macronutrients and trace elements are important components of living tissues that have different metabolic properties and functions. Trace elements participate in the regulation of immunity through humoral and cellular mechanisms, nerve conduction, muscle spasms, membrane potential regulation as well as mitochondrial activity and enzymatic reactions. Excessive alcohol consumption disrupts the concentrations of crucial trace elements, also increasing the risk of enhanced oxidative stress and alcohol-related liver diseases. In this review, we present the status of selected macroelements and trace elements in the serum and plasma of people chronically consuming alcohol. Such knowledge helps to understand the mechanisms of chronic alcohol-use disorder and to progress and prevent withdrawal effects, also improving treatment strategies.
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Earle M, Ault B, Bonney C. Euglycemic Diabetic Ketoacidosis in Concurrent Very Low-carbohydrate Diet and Sodium-glucose Transporter-2 Inhibitor Use: A Case Report. Clin Pract Cases Emerg Med 2020; 4:185-188. [PMID: 32426668 PMCID: PMC7219989 DOI: 10.5811/cpcem.2020.2.45904] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/13/2020] [Accepted: 02/21/2020] [Indexed: 01/27/2023] Open
Abstract
Introduction With the incredibly high incidence of Type 2 Diabetes in the current population of emergency department patients, it is critical for clinicians to understand the possible complications of the treatment of this disease. Medication like canagliflozin are more common to encounter on patient's home medication lists and clinicians should be aware of how these medications, alone or combined with dietary modifications, can result in significant pathology and even mortality if not appropriately treated. Case Report We report a case of a patient with type II diabetes mellitus who presented with euglycemic diabetic ketoacidosis in the setting of concurrent use of canagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, and strict adherence to a low-carbohydrate ketogenic diet for weight control. Discussion Euglycemic ketoacidosis has previously been observed in both diabetic and non-diabetic patients following strict ketogenic diets, as well as in diabetic patients being treated with SGLT-2 inhibitors. Conclusion As more patients choose ketogenic diets for weight control and diabetes management, clinicians should be aware of this potentially life-threatening complication in patients concurrently taking SGLT-2 inhibitors.
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Affiliation(s)
- Matthew Earle
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
| | - Brian Ault
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
| | - Caitlin Bonney
- University of Nevada Las Vegas, Department of Emergency Medicine, Las Vegas, Nevada
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Alabi FO, Alabi CO, Basso RG, Lakhdar N, Oderinde AO. Multiple electrolyte imbalances and mixed acid-base disorder posing a diagnostic dilemma: a case report. J Med Case Rep 2020; 14:15. [PMID: 31955708 PMCID: PMC6970286 DOI: 10.1186/s13256-019-2330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/03/2019] [Indexed: 11/22/2022] Open
Abstract
Background In clinical practice, both the history and laboratory testing are paramount to making an accurate diagnosis. Situations in which laboratory findings and patient history are not congruent pose a diagnostic dilemma. We report a case of a young woman presenting with a myriad of electrolyte and acid-base disorders. Difficulty in reaching a unifying diagnosis persisted due to discordant patient history. We believe this case shows that lab findings will clearly portray the problems a patient has and should be given more credence in a case where the history is discordant with lab findings. Case presentation A 28-year-old Hispanic American woman presented to the emergency room of our institution with a complaint of painless and sudden onset of stiffness in her upper and lower limbs. Associated weakness worse in the distal limbs was also reported. She experienced shortness of breath with minimal exertion, diaphoresis, and anxiety. Her vital signs revealed tachycardia without corresponding fever. She was conscious, oriented, and alert. Her physical exam revealed dry mucous membranes and warm extremities. She denied recent consumption of a large carbohydrate meal, diarrhea, vomiting, use of laxatives, and use of alcohol or recreational drugs. She vaguely described two previous similar episodes in the last 7 months that spontaneously resolved. Her medical history was significant only for hypothyroidism treated with daily levothyroxine tablets. Laboratory analysis revealed the following abnormalities: an elevated anion gap with significant lactate, hypokalemia, hypomagnesemia, elevated mean corpuscular volume, elevated mean cell hemoglobin, and elevated liver enzymes with aspartate aminotransferase/alanine aminotransferase ratio > 2. She was hydrated with balanced crystalloids, and her electrolyte deficiencies corrected. The etiology of her multiple electrolyte abnormalities was unclear because alcohol use was vehemently denied. Extensive evaluation for causes of electrolyte disorder was undertaken, which was unrevealing. On further interrogation, she admitted to recent alcohol intoxication and several episodes of vomiting before presentation. She was advised to refrain from alcohol use and discharged afterward. Conclusion Both patient history and laboratory analysis have a role in identifying and confirming a diagnosis. In cases in which laboratory tests are incongruous with reported history, making a unifying diagnosis can be challenging or delayed. The importance of taking a comprehensive history cannot be overemphasized, but history provided by patients may be prone to intentional or unintentional distortion, whereas laboratory findings are more objective. The case presented underscores why the lab findings should be given credence in cases in which there is discordance between lab results and the provided patient history.
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Affiliation(s)
- Fortune O Alabi
- Florida Lung Asthma and Sleep Specialists, Orlando, FL, USA.
| | | | | | - Nadia Lakhdar
- St. Matthew's University School of Medicine, Orlando, FL, USA
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Kim MK, Shin HW, Kim YJ, Yang JW, Kim JS, Han BG, Choi SO, Lee JY. Delta Neutrophil Index is Useful to Predict Poor Outcomes in Male Patients with Alcoholic Ketoacidosis. Electrolyte Blood Press 2019; 17:7-15. [PMID: 31338109 PMCID: PMC6629600 DOI: 10.5049/ebp.2019.17.1.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/05/2022] Open
Abstract
Background Alcoholic ketoacidosis (AKA) is known as a benign disease, but the related mortality reported in Korea is high. Acidosis and alcohol change the immunity profile, and these changes can be identified early using the delta neutrophil index (DNI). We aimed to evaluate the use of DNI and other standard laboratory parameters as predictors of prognosis in AKA patients. Methods One hundred eighteen males with AKA were evaluated at the Wonju Severance Christian hospital between 2009 and 2014. We performed a retrospective analysis of demographic, clinical, and laboratory parameters data. Receiver operating characteristic curves (ROC) and multivariate Cox regression was used to identify renal survival and mortality. Results Survival patients had lower initial DNI levels than non-survival patients (4.8±6.4 vs 11.4±12.5, p<0.001). In multivariate-adjusted Cox regression analysis, higher initial increased DNI (HR 1.044, 95% CI 1.003-1.086, p=0.035), and lower initial pH (HR 0.044, 95% CI 0.004-0.452, p=0.008) were risk factors for dialysis during hospitalization. Further, higher initial DNI level (HR 1.037; 95% CI 1.006-1.069; p=0.018), lower initial pH (HR 0.049; 95% CI 0.008-0.312; p=0.001) and lower initial glomerular filtration rate (GFR) (HR 0.981; 95% CI 0.964-0.999; p=0.033) were predictors of mortality. A DNI value of 4.5% was selected as the cut-off value for poor prognosis and Kaplan-Meier plots showed that AKA patients with an initial level DNI ≥4.5% had lower cumulative survival rates than AKA patients with an initial DNI <4.5%. Conclusion Increased initial serum DNI levels may help to predict renal survival and prognosis in male AKA patients.
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Affiliation(s)
- Min Keun Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Han Wul Shin
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - You Jin Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byoung-Geun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seung Ok Choi
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
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Jang HN, Park HJ, Cho HS, Bae E, Lee TW, Chang SH, Park DJ. The logistic organ dysfunction system score predicts the prognosis of patients with alcoholic ketoacidosis. Ren Fail 2019; 40:693-699. [PMID: 30741615 PMCID: PMC7011874 DOI: 10.1080/0886022x.2018.1491405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Alcoholic ketoacidosis (AKA) is occasionally associated with multiple complications leading to death. However, no study has yet evaluated prognostic factors in patients with AKA. It is known that the logistic organ dysfunction system (LODS) score is an objective and useful index to predict the prognosis. We used LODS score to predict prognosis of AKA. We retrospectively reviewed the medical records of 46 patients who were diagnosed as AKA in our hospital. The mean LODS score was 6.3. The probability of mortality based on the LODS score was 36.6%, and 16 patients (34.5%) did, in fact, die. The total LODS score and lactate dehydrogenase (LDH) were significantly higher in the non-survival group. Prothrombin activity, serum platelet number, and the serum albumin levels were significantly higher in the survival group. We found significant correlations between the LODS score and arterial pH, the albumin level, and the LDH concentration. Multivariate analysis showed that the serum albumin and LDH levels were independently associated with survival in AKA patients. AKA patients suffered high-level mortality and the LODS score was an accurate predictor of prognosis. Clinicians may use the LODS score to this end.
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Affiliation(s)
- Ha Nee Jang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Hee Jung Park
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Hyun Seop Cho
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea
| | - Eunjin Bae
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea
| | - Tae Won Lee
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea
| | - Se-Ho Chang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , South Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , South Korea.,d Institute of Health Science , Gyeongsang National University , Jinju , South Korea
| | - Dong Jun Park
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , South Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , South Korea.,d Institute of Health Science , Gyeongsang National University , Jinju , South Korea
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22
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Pflanz NC, Daszkowski AW, James KA, Mihic SJ. Ketone body modulation of ligand-gated ion channels. Neuropharmacology 2018; 148:21-30. [PMID: 30562540 DOI: 10.1016/j.neuropharm.2018.12.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/27/2018] [Accepted: 12/10/2018] [Indexed: 01/01/2023]
Abstract
Ketogenesis is a metabolic process wherein ketone bodies are produced from the breakdown of fatty acids. In humans, fatty acid catabolism results in the production of acetyl-CoA which can then be used to synthesize three ketone bodies: acetoacetate, acetone, and β-hydroxybutyrate. Ketogenesis occurs at a higher rate in situations of low blood glucose, such as during fasting, heavy alcohol consumption, and in situations of low insulin, as well as in individuals who follow a 'ketogenic diet' consisting of low carbohydrate and high fat intake. This diet has various therapeutic indications, including reduction of seizure likelihood in epileptic patients and alcohol withdrawal syndrome. However, the mechanisms underlying these therapeutic benefits are still unclear, with studies suggesting various mechanisms such as a shift in energy production in the brain, effects on neurotransmitter production, or effects on various protein targets. Two-electrode voltage clamp electrophysiology in Xenopus laevis oocytes was used to investigate the actions of ketone bodies on three ionotropic receptors: GABAA, glycine, and NMDA receptors. While physiologically-relevant concentrations of acetone have little effect on inhibitory GABA or glycine receptors, β-hydroxybutyrate inhibits the effects of agonists of these receptors at concentrations achieved in vivo. Additionally, both acetone and β-hydroxybutyrate act as inhibitors of glutamate at the excitatory NMDA receptor. Due to the role of hyperexcitability in the pathogenesis of epilepsy and alcohol withdrawal, the inhibitory actions of acetone and β-hydroxybutyrate at NMDA receptors may underlie the therapeutic benefit of a ketogenic diet for these disorders.
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Affiliation(s)
- Natasha C Pflanz
- Department of Neuroscience, Division of Pharmacology and Toxicology, Waggoner Center for Alcohol and Addiction Research, Institutes for Neuroscience and Cell and Molecular Biology, University of Texas at Austin, Austin, TX, 78712, USA
| | - Anna W Daszkowski
- Department of Neuroscience, Division of Pharmacology and Toxicology, Waggoner Center for Alcohol and Addiction Research, Institutes for Neuroscience and Cell and Molecular Biology, University of Texas at Austin, Austin, TX, 78712, USA
| | - Keith A James
- Department of Neuroscience, Division of Pharmacology and Toxicology, Waggoner Center for Alcohol and Addiction Research, Institutes for Neuroscience and Cell and Molecular Biology, University of Texas at Austin, Austin, TX, 78712, USA
| | - S John Mihic
- Department of Neuroscience, Division of Pharmacology and Toxicology, Waggoner Center for Alcohol and Addiction Research, Institutes for Neuroscience and Cell and Molecular Biology, University of Texas at Austin, Austin, TX, 78712, USA.
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Srinivasan MP, Shawky NM, Kaphalia BS, Thangaraju M, Segar L. Alcohol-induced ketonemia is associated with lowering of blood glucose, downregulation of gluconeogenic genes, and depletion of hepatic glycogen in type 2 diabetic db/db mice. Biochem Pharmacol 2018; 160:46-61. [PMID: 30529690 DOI: 10.1016/j.bcp.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/06/2018] [Indexed: 12/11/2022]
Abstract
Alcoholic ketoacidosis and diabetic ketoacidosis are life-threatening complications that share the characteristic features of high anion gap metabolic acidosis. Ketoacidosis is attributed in part to the massive release of ketone bodies (e.g., β-hydroxybutyrate; βOHB) from the liver into the systemic circulation. To date, the impact of ethanol consumption on systemic ketone concentration, glycemic control, and hepatic gluconeogenesis and glycogenesis remains largely unknown, especially in the context of type 2 diabetes. In the present study, ethanol intake (36% ethanol- and 36% fat-derived calories) by type 2 diabetic db/db mice for 9 days resulted in significant decreases in weight gain (∼19.5% ↓) and caloric intake (∼30% ↓). This was accompanied by a transition from macrovesicular-to-microvesicular hepatic steatosis with a modest increase in hepatic TG (∼37% ↑). Importantly, ethanol increased systemic βOHB concentration (∼8-fold ↑) with significant decreases in blood glucose (∼4-fold ↓) and plasma insulin and HOMA-IR index (∼3-fold ↓). In addition, ethanol enhanced hepatic βOHB content (∼5-fold ↑) and hmgcs2 mRNA expression (∼3.7-fold ↑), downregulated key gluconeogenic mRNAs (e.g., Pcx, Pck1, and G6pc), and depleted hepatic glycogen (∼4-fold ↓). Furthermore, ethanol intake led to significant decreases in the mRNA/protein expression and allosteric activation of glycogen synthase (GS) in liver tissues regardless of changes in the phosphorylation of GS, GSK-3β, or Akt. Together, our findings suggest that ethanol-induced ketonemia may occur in concomitance with significant lowering of blood glucose concentration, which may be attributed to suppression of gluconeogenesis in the setting of glycogen depletion in type 2 diabetes.
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Affiliation(s)
- Mukund P Srinivasan
- Center for Pharmacy and Experimental Therapeutics, University of Georgia College of Pharmacy, Augusta, GA, USA; Charlie Norwood VA Medical Center, Augusta, GA, USA; Department of Pathology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Noha M Shawky
- Center for Pharmacy and Experimental Therapeutics, University of Georgia College of Pharmacy, Augusta, GA, USA; Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Bhupendra S Kaphalia
- Department of Pathology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Muthusamy Thangaraju
- Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, USA
| | - Lakshman Segar
- Center for Pharmacy and Experimental Therapeutics, University of Georgia College of Pharmacy, Augusta, GA, USA; Charlie Norwood VA Medical Center, Augusta, GA, USA; Vascular Biology Center, Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, USA; Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA.
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Kacki S, Velemínský P, Lynnerup N, Kaupová S, Jeanson AL, Povýšil C, Horák M, Kučera J, Rasmussen KL, Podliska J, Dragoun Z, Smolík J, Vellev J, Brůžek J. Rich table but short life: Diffuse idiopathic skeletal hyperostosis in Danish astronomer Tycho Brahe (1546-1601) and its possible consequences. PLoS One 2018; 13:e0195920. [PMID: 29672561 PMCID: PMC5909615 DOI: 10.1371/journal.pone.0195920] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/02/2018] [Indexed: 12/16/2022] Open
Abstract
The exhumation of Danish astronomer Tycho Brahe (1546–1601) was performed in 2010 to verify speculative views on the cause of his death. Previous analyses of skeletal and hair remains recovered from his grave refuted the presumption that he died from poisoning. These studies also outlined the possibility that he actually died from an acute illness, echoing the rather vague and inaccurate testimony of some historical records. We performed a detailed paleopathological analysis of Tycho Brahe’s skeletal remains, along with a reconstruction of his diet based on carbon and nitrogen stable isotopes analysis and an estimate of his physical status (relative body fat) based on medullar and cortical dimensions of the femoral shaft. The astronomer’s remains exhibit bone changes indicative of diffuse idiopathic skeletal hyperostosis (DISH). The study further allows us to classify him as obese (100% reliability according to our decision tree designed from Danish males), and points out his rich diet (high input of animal protein and/or marine resources) and high social status. Comorbidities of DISH and obesity are reviewed, and their influence on health status is discussed. We further consider some conditions associated with metabolic syndrome as possible causes of Tycho Brahe’s final symptoms (urinary retention, renal failure and coma), including diabetes, alcoholic ketoacidosis and benign prostatic hypertrophy. Although a definite and specific diagnosis cannot be established, our study points to today’s civilization diseases often associated with DISH and metabolic syndrome as the possible cause of death of Tycho Brahe.
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Affiliation(s)
- Sacha Kacki
- Department of Archaeology, Durham University, Durham, United Kingdom
- PACEA–UMR 5199, University of Bordeaux, Pessac, France
| | - Petr Velemínský
- Department of Anthropology, National Museum, Prague, Czech Republic
- * E-mail:
| | - Niels Lynnerup
- Laboratory of Biological Anthropology, Institute of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sylva Kaupová
- Department of Anthropology, National Museum, Prague, Czech Republic
| | - Alizé Lacoste Jeanson
- Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
| | - Ctibor Povýšil
- Institute of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Horák
- Department of Radiology, Na Homolce Hospital, Prague, Czech Republic
| | - Jan Kučera
- Nuclear Physics Institute of Czech Academy of Sciences, Husinec-Řež, Czech Republic
| | - Kaare Lund Rasmussen
- Institute of Physics, Chemistry and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Jaroslav Podliska
- Department of Archaeology, National Heritage Institute, Prague, Czech Republic
| | - Zdeněk Dragoun
- Department of Archaeology, National Heritage Institute, Prague, Czech Republic
| | - Jiří Smolík
- Institute of Chemical Process Fundamentals of Czech Academy of Sciences, Prague, Czech Republic
| | - Jens Vellev
- Department of Culture and Society–Section for Medieval and Renaissance Archaeology, Aarhus University, Højbjerg, Denmark
| | - Jaroslav Brůžek
- PACEA–UMR 5199, University of Bordeaux, Pessac, France
- Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
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Torres L, Sánchez M, Cid B, Vicente E, Velasco R. A higher level of ketonaemia does not predict oral rehydration failure in vomiting paediatric patients and routine measurement is unnecessary. Acta Paediatr 2018; 107:714-717. [PMID: 29194756 DOI: 10.1111/apa.14173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/29/2017] [Accepted: 11/28/2017] [Indexed: 11/26/2022]
Abstract
AIM This study determined if blood levels of beta-hydroxybutyrate were associated with the rate of failure in oral rehydration in paediatric patients with vomiting. METHODS This was a prospective observational study that was carried out from December 1, 2015 to November 30, 2016 in the Rio Hortega University Hospital, Valladolid, Spain. The study cohort were patients up to 14 years old who attended the emergency department with three or more vomiting episodes in the last four hours and glycaemia higher than 45 mg/dL. Blood was measured for beta-hydroxybutyrate levels prior to the administration of oral rehydration solution for 90 minutes. Two or more vomiting episodes during this period were considered failed oral rehydration. RESULTS We analysed 248 patients, with a median age of four years and 7.5 months and 233 (94%) of the parents took part. The median number of vomiting episodes in the previous four hours was five and oral rehydration was successful in 183 (78.5%) patients. The multivariate analysis showed that the initial beta-hydroxybutyrate blood level was not associated with the failure of oral rehydration. CONCLUSION Blood levels of beta-hydroxybutyrate had no predictive value for oral rehydration failure in young patients with vomiting and this routine measurement is unnecessary.
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Affiliation(s)
- Lucía Torres
- Pediatric Emergency Unit; Pediatrics Department; Rio Hortega Universitary Hospital; Valladolid Spain
| | - Marina Sánchez
- Pediatric Emergency Unit; Pediatrics Department; Rio Hortega Universitary Hospital; Valladolid Spain
| | - Blanca Cid
- Pediatric Emergency Unit; Pediatrics Department; Rio Hortega Universitary Hospital; Valladolid Spain
| | - Eva Vicente
- Pediatric Emergency Unit; Pediatrics Department; Rio Hortega Universitary Hospital; Valladolid Spain
| | - Roberto Velasco
- Pediatric Emergency Unit; Pediatrics Department; Rio Hortega Universitary Hospital; Valladolid Spain
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26
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Affiliation(s)
- Biff F Palmer
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (B.F.P.); and the Department of Biomedical Sciences, Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles (D.J.C.)
| | - Deborah J Clegg
- From the Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (B.F.P.); and the Department of Biomedical Sciences, Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles (D.J.C.)
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Wang L, Zhu Y, Wang L, Hou J, Gao Y, Shen L, Zhang J. Effects of chronic alcohol exposure on ischemia-reperfusion-induced acute kidney injury in mice: the role of β-arrestin 2 and glycogen synthase kinase 3. Exp Mol Med 2017. [PMID: 28642577 PMCID: PMC5519017 DOI: 10.1038/emm.2017.76] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Little is known about the effects of chronic alcohol intake on the outcome of acute kidney injury (AKI). Hence, we examined the effects of chronic alcohol intake on the development of renal fibrosis following AKI in an animal model of bilateral renal ischemia–reperfusion (IR) injury. We first found that chronic alcohol exposure exacerbated bilateral IR-induced renal fibrosis and renal function impairment. This phenomenon was associated with increased bilateral IR-induced extracellular matrix deposition and an increased myofibroblast population as well as increased bilateral IR-induced expression of fibrosis-related genes in the kidneys. To explore the mechanisms underlying this phenomenon, we showed that chronic alcohol exposure enhanced β-arrestin 2 (Arrb2) expression and Akt and glycogen synthase kinase-3 (GSK3)β activation in the kidneys. Importantly, pharmacological GSK3 inhibition alleviated bilateral IR-induced renal fibrosis and renal function impairment. Furthermore, we demonstrated that Arrb2−/− mice exhibited resistance to IR-induced renal fibrosis and renal function impairment following chronic alcohol exposure, and these effects were associated with attenuated GSK3β activation in the kidneys. Taken together, our results suggest that chronic alcohol exposure may potentiate AKI via β-arrestin 2/Akt/GSK3β-mediated signaling in the kidney.
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Affiliation(s)
- Lihua Wang
- Division of Blood Purification, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yifei Zhu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lili Wang
- Division of Blood Purification, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingjing Hou
- Division of Blood Purification, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yongning Gao
- Division of Blood Purification, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Shen
- Division of Blood Purification, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingyu Zhang
- Department of Hematology, The Second Hospital of Hebei Medical University, Key Laboratory of Hematology of Hebei Province, Shijiazhuang, Hebei, China
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Ruzsányi V, Péter Kalapos M. Breath acetone as a potential marker in clinical practice. J Breath Res 2017; 11:024002. [DOI: 10.1088/1752-7163/aa66d3] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Humphries CP. Lower Respiratory Tract Infection: An Unrecognised Risk Factor for High Altitude Pulmonary Oedema? Eur J Case Rep Intern Med 2017; 4:000539. [PMID: 30755928 PMCID: PMC6346869 DOI: 10.12890/2017_000539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/16/2016] [Indexed: 12/02/2022] Open
Abstract
The case of a 25-year-old expedition doctor who developed high altitude pulmonary oedema (HAPE) while climbing in the Swiss Alps is presented, with reference to the literature. The patient’s symptoms of HAPE were typical. Less typical was the fact that the doctor had previously been to similar altitudes uneventfully. The only differentiator is that on this expedition he developed a mild lower respiratory tract infection (LRTI) 2 days prior to travel. There has been limited, conflicting evidence regarding LRTI as a risk factor for HAPE and high quality research has not focused on this area. LRTI is not commonly recognised as being a risk in high altitude environments, which may be resulting in lethal consequences. This report aims to inform, provide a clinical question for future high altitude research expeditions, and encourage consideration by expedition and high altitude doctors.
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Icin T, Medic-Stojanoska M, Ilic T, Kuzmanovic V, Vukovic B, Percic I, Kovacev-Zavisic B. Multiple Causes of Hyponatremia: A Case Report. Med Princ Pract 2017; 26:292-295. [PMID: 28268230 PMCID: PMC5588416 DOI: 10.1159/000468938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To present a case with 4 different potential causes of hyponatremia. CLINICAL PRESENTATION AND INTERVENTION The patient presented with the following symptoms: nausea, vomiting, diarrhea, and dark urine after drinking large amounts of fluids that included alcohol and caffeine. Laboratory, microbiological, and morphological examinations revealed the existence of severe hyponatremia and acute poststreptococcal glomerulonephritis. The patient developed acute symptomatic seizures and coma. Gradual normalization of the sodium level led to a recovery of consciousness. CONCLUSION Treatment with hypertonic sodium, fluid restriction, and antibiotics led to a complete recovery. In the case of multiple causes of hyponatremia, it is necessary to treat all causes.
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Affiliation(s)
- Tijana Icin
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
- *Tijana Icin, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Hajduk Veljkova 1-3, RS-21000 Novi Sad (Serbia), E-Mail
| | - Milica Medic-Stojanoska
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Tatjana Ilic
- Clinic of Nephrology and Clinical Immunology, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Vladimir Kuzmanovic
- Department of Internal Medicine, General Hospital, Sremska Mitrovica, Serbia
| | - Bojan Vukovic
- Clinic of Emergency Center, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Ivanka Percic
- Clinic of Emergency Center, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Branka Kovacev-Zavisic
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
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Boutin CA, Laskine M. Ketoacidosis in a Non-Diabetic Adult With Chronic EtOH Consumption. J Clin Med Res 2016; 8:919-920. [PMID: 27829960 PMCID: PMC5087634 DOI: 10.14740/jocmr2751w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 11/16/2022] Open
Abstract
Although much more rare than its diabetic counterpart, ketoacidosis secondary to alcohol withdrawal in the context of fasting has its own complex pathophysiology and can easily mimic the acute insulin deficiency presentation. We present here a rare case of a non-diabetic alcoholic patient who presented in ketoacidosis after a period of reduced intake.
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Affiliation(s)
- Catherine-Audrey Boutin
- Department of Medicine, Centre Hospitalier de l'Universite de Montreal (CRCHUM), Montreal, QC, H2W 1T8, Canada
| | - Mikhael Laskine
- Department of Medicine, Centre Hospitalier de l'Universite de Montreal (CRCHUM), Montreal, QC, H2W 1T8, Canada
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Noor NM, Basavaraju K, Sharpstone D. Alcoholic ketoacidosis: a case report and review of the literature. Oxf Med Case Reports 2016; 2016:31-3. [PMID: 26949539 PMCID: PMC4776050 DOI: 10.1093/omcr/omw006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/19/2016] [Accepted: 01/21/2016] [Indexed: 01/02/2023] Open
Abstract
Alcoholic ketoacidosis (AKA) is a cause of severe metabolic acidosis usually occurring in malnourished patients with a history of recent alcoholic binge, often on a background of alcohol dependency. AKA can be fatal due to associated electrolyte abnormalities and subsequent development of cardiac arrhythmias. This is a diagnosis that is often delayed or missed, in patients who present with a severe lactic and ketoacidosis. Here we report the case of a 64-year-old female who presented with generalized abdominal pain, nausea and shortness of breath. Blood gas analysis showed significant acidaemia with a pH of 7.10, bicarbonate of 2.9 mmol/l, and lactate of 11.7 mmol/l. Serum ketones were raised at 5.5 mmol/l. The diagnosis of AKA was suspected, and subsequent aggressive fluid resuscitation, management and monitoring were instituted. Given the early recognition of AKA and appropriate multidisciplinary team management, our patient had a good outcome and was discharged home without any complication.
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Affiliation(s)
- Nurulamin M Noor
- Department of Medicine , University of Cambridge , Cambridge , UK
| | - Krishna Basavaraju
- Department of Gastroenterology , West Suffolk Hospital , Bury St Edmunds , UK
| | - Dan Sharpstone
- Department of Gastroenterology , West Suffolk Hospital , Bury St Edmunds , UK
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Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, Bornstain C, Vincent F. Les pièges de l’acidocétose diabétique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Prater J, Chaiban JT. Euglycemic Diabetic Ketoacidosis with Acute Pancreatitis in a Patient Not Known to Have Diabetes. AACE Clin Case Rep 2015. [DOI: 10.4158/ep14182.cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hendrikx JJMA, Lagas JS, Daling R, Hooijberg JH, Schellens JHM, Beijnen JH, Brandjes DPM, Huitema ADR. Severe Lactic Acidosis in a Diabetic Patient after Ethanol Abuse and Floor Cleaner Intake. Basic Clin Pharmacol Toxicol 2014; 115:472-5. [DOI: 10.1111/bcpt.12251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/03/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | - Jurjen S. Lagas
- Department of Pharmacy & Pharmacology; Slotervaart Hospital; Amsterdam The Netherlands
| | - Ratana Daling
- Department of Intensive Care; Slotervaart Hospital; Amsterdam The Netherlands
| | - Jan Hendrik Hooijberg
- Department of Clinical Chemistry and Hematology; Slotervaart Hospital; Amsterdam The Netherlands
| | - Jan H. M. Schellens
- Department of Clinical Pharmacology; The Netherlands Cancer Institute; Amsterdam The Netherlands
- Department of Pharmaceutical Sciences; Science Faculty; Utrecht University; Utrecht The Netherlands
| | - Jos H. Beijnen
- Department of Pharmacy & Pharmacology; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Clinical Pharmacology; The Netherlands Cancer Institute; Amsterdam The Netherlands
- Department of Pharmaceutical Sciences; Science Faculty; Utrecht University; Utrecht The Netherlands
| | | | - Alwin D. R. Huitema
- Department of Pharmacy & Pharmacology; Slotervaart Hospital; Amsterdam The Netherlands
- Department of Clinical Pharmacology; The Netherlands Cancer Institute; Amsterdam The Netherlands
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36
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Adams C. Anaesthetic implications of acute and chronic alcohol abuse. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2010.10872680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Yokoyama A, Yokoyama T, Mizukami T, Matsui T, Shiraishi K, Kimura M, Matsushita S, Higuchi S, Maruyama K. Alcoholic Ketosis: Prevalence, Determinants, and Ketohepatitis in Japanese Alcoholic Men. Alcohol Alcohol 2014; 49:618-25. [DOI: 10.1093/alcalc/agu048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/03/2014] [Indexed: 11/13/2022] Open
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Abstract
In the 21st century, alcoholism and the consequences of ethyl alcohol abuse are major public health concerns in the United States, affecting approximately 14 million people. Pertinent to the global impact of alcoholism is the World Health Organisation estimate that 140 million people worldwide suffer from alcohol dependence. Alcoholism and alcohol abuse are the third leading causes of preventable death in the United States. Alcohol dependence and alcohol abuse cost the United State an estimated US$220 billion in 2005, eclipsing the expense associated with cancer (US$196 billion) or obesity (US$133 billion). Orally ingested ethyl alcohol is absorbed rapidly without chemical change from the stomach and intestine, reaching maximum blood concentration in about an hour. Alcohol crosses capillary membranes by simple diffusion, affecting almost every organ system in the body by impacting a wide range of cellular functions. Alcohol causes metabolic derangements either directly, via its chemical by-product or secondarily through alcohol-induced disorders. Many of these alcohol-related metabolic disturbances are increased in severity by the malnutrition that is common in those with chronic alcoholism. This review focuses on the acute and chronic injurious consequences of alcohol ingestion on the kidney, as well as the fluid, electrolyte and acid-base abnormalities associated with acute and chronic ingestion of alcohol.
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Affiliation(s)
- Adebayo Adewale
- Department of Medicine, Kingsbrook Jewish Medical Center, Brooklyn, USA
| | - Onyekachi Ifudu
- Division of Nephrology, St. John's Episcopal Hospital, Southshore, New York, USA
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39
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Milroy CM. Sudden Death and Chronic Alcoholism. Acad Forensic Pathol 2014. [DOI: 10.23907/2014.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Alcohol is a common factor in many deaths. Chronic alcoholics may die suddenly from trauma, intoxication, and from preexisting disease. In many cases, there is no obvious cause of death in chronic alcoholics following initial postmortem examination. Determining the cause of death in chronic alcoholics can be challenging. Such deaths in chronic alcoholics may be due to a number of mechanisms, including alcoholic ketoacidosis and disorders of cardiac rhythm. Alcoholic ketoacidosis has been recognized as a cause of death since the 1990s. It can be diagnosed by postmortem analysis of ketone bodies, including acetone and β-hydroxybutyrate. It has been recognized clinically that patients with alcoholic liver disease have prolongation of the QT interval and a risk of sudden death. This paper reviews sudden natural deaths in chronic alcoholics, discussing pathological processes and mechanisms of death, especially where the cause of death is not obvious on initial autopsy.
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Affiliation(s)
- Christopher M. Milroy
- Eastern Ontario Regional Forensic Pathology Unit, The Ottawa Hospital and University of Ottawa in Ottawa, Canada
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40
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Chandrasekara H, Fernando P, Danjuma M, Jayawarna C. Ketoacidosis is not always due to diabetes. BMJ Case Rep 2014; 2014:bcr-2013-203263. [PMID: 24569261 DOI: 10.1136/bcr-2013-203263] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chronic alcoholism is a frequently unrecognised cause of ketoacidosis. Most patients with alcoholic ketoacidosis present with normal or low glucose, but this condition can present with hyperglycaemia. This can lead to misdiagnosis of diabetes ketoacidosis and, therefore, inappropriate treatment with insulin. We describe a 37-year-old Caucasian woman with chronic pancreatitis secondary to excess alcohol consumption, admitted with abdominal pain and vomiting, fulfilling the criteria for diabetes ketoacidosis. She was treated according to diabetes ketoacidosis protocol and experienced a hypoglycaemic attack within an hour of initiation of insulin. On review of her history, she was found to have three similar episodes over the past 12 months. Alcoholic ketoacidosis can present with hyperglycaemia due to relative deficiency of insulin and relative surplus in counter-regulatory stress hormones including glucagon. Awareness of the syndrome with a detailed history helps to differentiate alcohol ketoacidosis from diabetes ketoacidosis and prevent iatrogenic hypoglycaemia.
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Suzuki K, Tamai Y, Urade S, Ino K, Sugawara Y, Katayama N, Hoshino T. Alcoholic ketoacidosis that developed with a hypoglycemic attack after eating a high-fat meal. Acute Med Surg 2013; 1:109-114. [PMID: 29930832 DOI: 10.1002/ams2.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 10/30/2013] [Indexed: 02/06/2023] Open
Abstract
Case Alcoholic ketoacidosis (AKA) usually occurs in patients with a history of prolonged alcohol abuse and recent binge drinking followed by abrupt cessation of alcohol consumption. Outcome A 61-year-old man was brought to our emergency department. He had a history of eating barbecued beef with beer the previous night. He had unexplained hypoglycemia with high anion gap metabolic acidosis and fatty liver, and we strongly suspected AKA. After hydration with saline solution, dextrose, and thiamine, given i.v., his metabolic acidosis rapidly improved. A history of alcohol abuse and high serum β-hydroxybutyrate concentration were subsequently confirmed, and the diagnosis of AKA was finally made. Conclusion Our case suggests that a high-fat meal can induce AKA without abrupt cessation of alcohol consumption and that AKA should be considered when encountering patients with unexplained high anion gap metabolic acidosis with hypoglycemia and fatty liver, even if the past history of alcohol abuse is unknown.
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Affiliation(s)
- Kei Suzuki
- Department of Emergency Medicine Matsusaka Chuo Hospital Matsusaka Mie Japan.,Department of Hematology and Oncology Mie University Graduate School of Medicine Mie Japan
| | - Yasuyuki Tamai
- Department of Gastroenterology Matsusaka Chuo Hospital Matsusaka Mie Japan
| | - Shinji Urade
- Department of Gastroenterology Matsusaka Chuo Hospital Matsusaka Mie Japan
| | - Kazuko Ino
- Department of Emergency Medicine Matsusaka Chuo Hospital Matsusaka Mie Japan.,Department of Hematology and Oncology Mie University Graduate School of Medicine Mie Japan
| | - Yumiko Sugawara
- Department of Emergency Medicine Matsusaka Chuo Hospital Matsusaka Mie Japan.,Department of Hematology and Oncology Mie University Graduate School of Medicine Mie Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology Mie University Graduate School of Medicine Mie Japan
| | - Tamotsu Hoshino
- Department of Emergency Medicine Matsusaka Chuo Hospital Matsusaka Mie Japan
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Palmiere C, Augsburger M. The postmortem diagnosis of alcoholic ketoacidosis. Alcohol Alcohol 2013; 49:271-81. [PMID: 24334515 DOI: 10.1093/alcalc/agt177] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIMS The aim of this article is to review the forensic literature covering the postmortem investigations that are associated with alcoholic ketoacidosis fatalities and report the results of our own analyses. METHODS Eight cases of suspected alcoholic ketoacidosis that had undergone medico-legal investigations in our facility from 2011 to 2013 were retrospectively selected. A series of laboratory parameters were measured in whole femoral blood, postmortem serum from femoral blood, urine and vitreous humor in order to obtain a more general overview on the biochemical and metabolic changes that occur during alcoholic ketoacidosis. Most of the tested parameters were chosen among those that had been described in clinical and forensic literature associated with alcoholic ketoacidosis and its complications. RESULTS Ketone bodies and carbohydrate-deficient transferrin levels were increased in all cases. Biochemical markers of generalized inflammation, volume depletion and undernourishment showed higher levels. Adaptive endocrine reactions involving insulin, glucagon, cortisol and triiodothyronine were also observed. CONCLUSIONS Metabolic and biochemical disturbances characterizing alcoholic ketoacidosis can be reliably identified in the postmortem setting. The correlation of medical history, autopsy findings and biochemical results proves therefore decisive in identifying pre-existing disorders, excluding alternative causes of death and diagnosing alcoholic ketoacidosis as the cause of death.
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Affiliation(s)
- Cristian Palmiere
- Corresponding author: University Center of Legal Medicine, Rue du Bugnon 21, 1011 Lausanne, Switzerland.
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Singh VP, Singh N, Jaggi AS. A review on renal toxicity profile of common abusive drugs. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2013; 17:347-57. [PMID: 23946695 PMCID: PMC3741492 DOI: 10.4196/kjpp.2013.17.4.347] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 06/25/2013] [Accepted: 07/14/2013] [Indexed: 12/22/2022]
Abstract
Drug abuse has become a major social problem of the modern world and majority of these abusive drugs or their metabolites are excreted through the kidneys and, thus, the renal complications of these drugs are very common. Morphine, heroin, cocaine, nicotine and alcohol are the most commonly abused drugs, and their use is associated with various types of renal toxicity. The renal complications include a wide range of glomerular, interstitial and vascular diseases leading to acute or chronic renal failure. The present review discusses the renal toxicity profile and possible mechanisms of commonly abused drugs including morphine, heroin, cocaine, nicotine, caffeine and alcohol.
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Affiliation(s)
- Varun Parkash Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala-147002, India
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44
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Celik S, Karapirli M, Kandemir E, Ucar F, Kantarcı MN, Gurler M, Akyol O. Fatal ethyl and methyl alcohol-related poisoning in Ankara: A retrospective analysis of 10,720 cases between 2001 and 2011. J Forensic Leg Med 2013; 20:151-4. [DOI: 10.1016/j.jflm.2012.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 04/21/2012] [Accepted: 05/29/2012] [Indexed: 12/27/2022]
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45
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Dwyer JB, Tamama K. Ketoacidosis and trace amounts of isopropanol in a chronic alcoholic patient. Clin Chim Acta 2013; 415:245-9. [DOI: 10.1016/j.cca.2012.10.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 10/26/2012] [Accepted: 10/27/2012] [Indexed: 10/27/2022]
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46
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Cartwright MM, Hajja W, Al-Khatib S, Hazeghazam M, Sreedhar D, Li RN, Wong-McKinstry E, Carlson RW. Toxigenic and Metabolic Causes of Ketosis and Ketoacidotic Syndromes. Crit Care Clin 2012; 28:601-31. [DOI: 10.1016/j.ccc.2012.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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47
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Postmortem measurement of C-reactive protein and interpretation of results in ketoacidosis. Leg Med (Tokyo) 2012; 14:140-6. [DOI: 10.1016/j.legalmed.2012.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/19/2012] [Accepted: 01/20/2012] [Indexed: 11/30/2022]
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Platteborze PL, Rainey PM, Baird GS. Ketoacidosis with unexpected serum isopropyl alcohol. Clin Chem 2011; 57:1361-4. [PMID: 21956919 DOI: 10.1373/clinchem.2010.157248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Peter L Platteborze
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, WA 98195, USA
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49
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Palmiere C, Mangin P. Postmortem chemistry update part I. Int J Legal Med 2011; 126:187-98. [PMID: 21947676 DOI: 10.1007/s00414-011-0625-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 09/09/2011] [Indexed: 11/30/2022]
Abstract
Postmortem chemistry is becoming increasingly essential in the forensic pathology routine and considerable progress has been made over the past years. Biochemical analyses of vitreous humor, cerebrospinal fluid, blood and urine may provide significant information in determining the cause of death or in elucidating forensic cases. Postmortem chemistry may essentially contribute in the determination of the cause of death when the pathophysiological changes involved in the death process cannot be detected by morphological methods (e.g. diabetes mellitus, alcoholic ketoacidosis and electrolytic disorders). It can also provide significant information and useful support in other forensic situations, including anaphylaxis, hypothermia, sepsis and hormonal disturbances. In this article, we present a review of the literature that covers this vast topic and we report the results of our observations. We have focused our attention on glucose metabolism, renal function and electrolytic disorders.
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Affiliation(s)
- Cristian Palmiere
- University Centre of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011, Lausanne, Switzerland.
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50
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Kraut JA, Xing SX. Approach to the Evaluation of a Patient With an Increased Serum Osmolal Gap and High-Anion-Gap Metabolic Acidosis. Am J Kidney Dis 2011; 58:480-4. [DOI: 10.1053/j.ajkd.2011.05.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 05/16/2011] [Indexed: 11/11/2022]
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